High-resolution Magnetic Resonance Imaging of Symptomatic Middle Cerebral Artery Dissection

RNF213 Polymorphisms in Intracranial Artery Dissection

The ring finger protein 213 gene (RNF213) is involved in several vascular diseases, both intracranial and systemic ones. Some variants are common in the Asian population and are reported as a risk factor for moyamoya disease, intracranial stenosis and intracranial aneurysms. Among intracranial vascular diseases, both moyamoya disease and intracranial artery dissection are more prevalent in the Asian population. We performed a systematic review of the literature, aiming to assess the rate of RNF213 variants in patients with spontaneous intracranial dissections. Four papers were identified, providing data on 53 patients with intracranial artery dissection. The rate of RNF213 variants is 10/53 (18.9%) and it increases to 10/29 (34.5%), excluding patients with vertebral artery dissection. All patients had the RNF213 p.Arg4810Lys variant. RNF213 variants seems to be involved in intracranial dissections in Asian cohorts. The small number of patients, the inclusion of only patients of Asian descent and the small but non-negligible coexistence with moyamoya disease familiarity might be limiting factors, requiring further studies to confirm these preliminary findings and the embryological interpretation.

Subarachnoid hemorrhage due to middle cerebral artery dissection mimicking aneurysm - Case report

We report a case of subarachnoid hemorrhage due to a dissecting middle cerebral artery that was misdiagnosed as saccular aneurysm. A 74-years old female patient presented with headache and neck pain for 4 days. Brain magnetic resonance imaging revealed subarachnoid hemorrhage in both Sylvian fissures. A ruptured left middle cerebral artery bifurcation saccular aneurysm and unruptured basilar tip aneurysm were diagnosed. The patient was treated surgically using the transsylvian approach. However, no saccular aneurysm was found during the surgery, and the diagnosis was corrected for middle cerebral artery dissection. We treated the dissected segment of the middle cerebral artery and performed clip reinforcement. We experienced a case of middle cerebral artery dissection with no neurological deficit, which was misdiagnosed as a saccular aneurysm. If the stump of the occlusion is conical, dissection should be suspected. High-resolution magnetic resonance imaging and angiography should be performed for a differential diagnosis if dissection is suspected.

Characteristics of Symptomatic Basilar Artery Stenosis Using High-Resolution Magnetic Resonance Imaging in Ischemic Stroke Patients

Aim: Arterial narrowing associated with the progression of atherosclerosis leads to serious conditions such as stroke, coronary artery disease, or even death. High-resolution magnetic resonance imaging (HR-MRI) is better for detecting arterial wall status and discriminating tissue characteristics than conventional imaging. We used HR-MRI to investigate the frequency of patients with basilar artery (BA) stenosis observed distinctively on routine angiography and identify the clinical features associated with this imaging. We analyzed the nature of the vessel wall causing the basal artery stenosis by HR-MRI, and related clinical factors.

Methods: Patients with BA stenosis underwent HR-MRI. The association between atherosclerosis (with or without intraplaque hemorrhage [IPH]) and dissection was analyzed. High signal intensity within a BA plaque on magnetization-prepared rapid acquisition with gradient echo was defined as an area with a signal intensity ＞200% that of the adjacent muscle.

Results: Fifteen patients were diagnosed with BA dissection on HR-MRI. IPH was identified in 14 patients. Patients with BA plaque with IPH were older and had higher prevalence of hypertension and hyperlipidemia than the other patients. The frequencies of alcohol drinking and number of current smokers were higher in the dissection group than in the other groups. Hyperlipidemia was identified as an influencing factor for IPH development in atherosclerotic plaque. Young age was identified as the influencing factor for the occurrence of BA dissection.

Conclusions: The etiology of stenosis or occlusion was unclear until the development of HR-MRI. With HR-MRI, stroke etiology is better understood, and factors affecting each etiology can be identified. Further studies that clarify the etiology of posterior circulation stroke are required.

Differential Diagnosis of Intraplaque Hemorrhage and Dissection on High-Resolution MR Imaging in Patients with Focal High Signal of the Vertebrobasilar Artery on TOF Imaging

PURPOSE

Intraplaque hemorrhage (IPH) and dissection in the vertebrobasilar artery (VBA) on time of flight (TOF) source imaging are seen as focal eccentric high-signal intensity. The purpose of this study is to identify IPH and dissection in the VBA using high-resolution magnetic resonance imaging (HR-MRI).

METHODS

A total of 78 patients (VBA IPH: 55; dissection: 23) with focal high-signal intensity in the VBA on simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP) of HR-MRI were included in this study. The focal high-signal intensity in the VBA on SNAP was defined as >200% than that of the adjacent muscle. We analyzed the signal intensity ratio (area of focal high signal intensity area/lumen) on TOF imaging and black blood (BB) T2-weighted imaging.

RESULTS

The VBA IPH group was older than the dissection group and had more hypertension. Signal intensity of a false lumen in patients with dissection on TOF imaging was significantly higher than that of VBA IPH (p < 0.001). The signal intensity ratio between lumen and lesion on TOF imaging was significantly higher in the dissection group (p < 0.001). The signal intensity of a false lumen in patients with dissection on BB T2-weighted imaging was significantly lower than that of VBA IPH (p < 0.001). The signal intensity ratio between lumen and lesion on BB T2-weighted imaging was significantly higher in the VBA IPH group (p < 0.001).

CONCLUSIONS

TOF imaging and BB T2-weighted imaging on HR-MRI in patients with focal eccentric high-signal intensity on TOF imaging can distinguish between VBA IPH and dissection.

Image Findings of Acute to Subacute Craniocervical Arterial Dissection on Magnetic Resonance Vessel Wall Imaging: A Systematic Review and Proportion Meta-Analysis

Background and Purpose: This systematic review and meta-analysis aimed to evaluate the pooled proportion of image findings of acute to subacute craniocervical arterial dissection (AD) direct signs on magnetic resonance vessel wall imaging (MR-VWI) and to identify factors responsible for the heterogeneity across the included studies.

Methods: A systematic literature search in the Ovid-MEDLINE and EMBASE databases was performed for studies published on the relevant topic before April 14, 2020. Pooled sensitivity and specificity values and their 95% confidence intervals (CIs) were calculated using bivariate random-effects modeling. Meta-regression analyses were also performed to determine factors influencing heterogeneity.

Results: Eleven articles with data for 209 patients with acute to subacute craniocervical AD who underwent MR-VWI were included in this systematic review and meta-analysis. The most common findings on MR-VWI were wall hematoma (84%; 95% CI, 71%−92%), abnormal enhancement (72%; 95% CI, 49%−88%), aneurysmal dilatation (71%, 95% CI, 53%−84%), and intimal flap or double lumen signs (49%; 95% CI, 29%−71%). Among the potential covariates of heterogeneity, the presence of contrast-enhanced T1-weighted imaging (CE-T1WI) within the MR-VWI sequence combination significantly affected the pooled proportion of the intimal flap or double lumen signs.

Conclusion: Wall hematoma and intimal flap or double lumen signs were the most common and least common direct sign image findings, respectively, on MR-VWI in patients with acute to subacute craniocervical AD. Furthermore, the absence of CE-T1WI in MR-VWI protocol was the cause of heterogeneity for the detection of the intimal flap or double lumen signs. This data may help improve MR-VWI interpretation and enhance the understanding of the radiologic diagnosis of craniocervical AD.

Endovascular Approach in Patients with Acute Complete Occlusion Due to Middle Cerebral Artery Dissection

Objective

Dissection of the middle cerebral artery (MCA) is less common than dissection of vessels in the vertebrobasilar system or carotid artery. Acute complete occlusion related to MCA dissection is extremely rare. We report an endovascular approach in patients with acute complete occlusion due to MCA dissection.

Methods

We reviewed retrospectively the endovascular procedure and clinical results for acute-stroke patients who underwent recanalization from October 2014 through December 2018. Initial imaging findings and the endovascular procedure were analyzed for patients with acute complete occlusion due to MCA dissection.

Results

We undertook first-line aspiration thrombectomy using a Penumbra catheter in 294 patients with acute occlusion of the M1 segment. Of these patients, seven were confirmed to have acute complete occlusion due to MCA dissection. All patients had angiographic findings of an intimal flap at the proximal occlusion site of the MCA. One patient complained of severe headache during microcatheter passage through the occluded lesion and died due to massive bleeding caused by rupture of the false lumen. The remaining patients underwent initial contact aspiration thrombectomy without microcatheter passage. After aspiration thrombectomy, six patients had delayed flow through the MCA. One patient underwent stenting of the MCA because of progressive symptoms.

Conclusion

An intimal flap at the proximal portion of an occluded MCA can suggest the possibility of MCA dissection. Contrast aspiration thrombectomy without microcatheter passage can reduce the risk of false lumen rupture in cases of MCA dissection.

Positional headache induced by isolated middle cerebral artery dissection: Two case reports

BACKGROUND

Isolated middle cerebral artery dissection is uncommon and occurs in patients reporting headaches as the only symptom. This makes intracranial artery dissection challenging to diagnose and treat.Case description: We describe two cases of positional headache caused by isolated middle cerebral artery dissection, confirmed using high-resolution magnetic resonance imaging. The two patients presented with sudden-onset headache, occurring when lying in the lateral decubitus position. When lying down in the decubitus position ipsilateral to the intracranial artery dissection, the headache aggravated and middle cerebral artery flow velocity increased on transcranial Doppler ultrasonography compared to when in the supine position. Both patients were treated with antiplatelet agents, and the headache completely resolved within 1-2 weeks.

CONCLUSION

We recommend additional imaging studies evaluating intracranial artery dissection as a cause of positional headache.

Late delayed radiation-induced cerebral Arteriopathy by high-resolution magnetic resonance imaging: a case report

Background

Radiation therapy can cause cerebral arteriopahty, resulting in ischemic stroke. We document late-delayed cerebral arteriopathy by high-resolution magnetic resonance imaging (HR-MRI) in a middle aged man who had cranial irradiation 19 years earlier.

Case presentation

A 45-year-old man was diagnosed with frontal lobe glioma 19 years ago and was treated with radiation after surgical resection. He was admitted to our hospital with an acute cerebral infarction in November 8, 2017. Traditional MRI examination and HR-MRI (sagittal, reconstruction of coronal and axial) were performed at admission. He was treated with prednisone (30 mg/day) and clinical symptoms disappeared after 3 months by telephone follow-up. Our patient complained of dizziness and blurred vision and traditional MRI examination indicated acute ischemic stroke in temporal lobe and occipital lobe and microbleeds. In order to define the exact mechanism of stroke, blood tests, auto-immune screening and thrombophilia were performed and results were normal. Electrocardiography and echocardiography were negative and cardiogenic cerebral embolism was excluded. In cerebrospinal fluid (CSF) examination, level of albumin and IgG were elevated. HR-MRI showed vessel wall thickening in T1-weighted imaging, narrow lumen in proton density imaging and vessel wall concentric enhancement in contrast-enhanced T1- weighted imaging. Combined with radiotherapy history, the patient was diagnosed with radioactive vasculitis.

Conclusion

Radiation-induced cerebrovascular damages could be a lasting progress, which we cannot ignore. HR-MRI can provide sensitive and accurate diagnostic assessment of radiation-induced arteritis and may be a useful tool for the screening of causes of cryptogenic stroke.

Magnetic resonance imaging of intracranial atherosclerosis: Comparison of ex vivo 3T MRI and histologic findings

PURPOSE

Imaging the lipid-rich necrotic core (LRNC) is very important when evaluating the response of lipid-lowering therapy. The purpose of this study was to assess ex vivo LRNC of intracranial atherosclerosis using 3T MRI.

MATERIALS AND METHODS

Thirty-one atherosclerotic lesions from 17 specimens were analyzed (basilar artery=15, middle cerebral artery=16) using 3T MRI. Specimens were not chemically processed for imaging studies. Reconstructed MRI was matched with histologic sections at corresponding locations.

RESULTS

The median plaque thickness of intracranial atherosclerosis was 0.6mm (0.4-2.0mm). All specimens had a LRNC on histologic findings. Three specimens had plaque calcification on histologic findings. LRNC of 30 specimens (96.8%) appeared as homogeneous isointensity/hypointensity on T1-weighted imaging and hypointensity on T2-weighted imaging compared with T1-weighted imaging.

CONCLUSIONS

All specimens with ex vivo intracranial atherosclerosis had LRNC. Intracranial atherosclerosis could be an indication for lipid-lowering therapy, similar to previous carotid MR studies.

Comparison of 3D magnetic resonance imaging and digital subtraction angiography for intracranial artery stenosis

OBJECTIVES

To compare three-dimensional high-resolution magnetic resonance imaging (3D HR-MRI) and digital subtraction angiography (DSA) for diagnosing and evaluating stenosis in the entire circle of Willis.

METHODS

The study included 516 intracranial arteries from 43 patients with intracranial artery stenosis (ICAS) who underwent both 3D HR-MRI and DSA within 1 month. Two readers independently diagnosed atherosclerosis, dissection, moyamoya disease and vasculitis, rated their diagnostic confidence for each vessel and measured the luminal diameters. Reference standard was made from clinico-radiologic diagnosis. Diagnostic accuracy, diagnostic confidence, the degree of stenosis and luminal diameter were assessed and compared between both modalities.

RESULTS

For atherosclerosis, 3D HR-MRI showed better diagnostic accuracy (P = .03-.003), sensitivity (P = .006-.01) and positive predictive value (P ≤ .001-.006) compared to DSA. Overall, the readers were more confident of their diagnosis of ICAS when using 3D HR-MRI (reader 1, P ≤ .001-.007; reader 2, P ≤ .001-.015). 3D HR-MRI showed similar degree of stenosis (P > .05) and higher luminal diameter (P < .05) compared to DSA.

CONCLUSIONS

3D HR-MRI might be useful to evaluate atherosclerosis, with better diagnostic confidence and comparable stenosis measurement compared to DSA in the entire circle of Willis.

KEY POINTS

• 3D HR-MRI showed better diagnostic accuracy for atherosclerosiscompared to DSA • 3D HR-MRI showed better overall diagnostic confidence for stenosiscompared to DSA • 3D HR-MRI and DSA showed similar degree of stenosis.

Comparison of High-Resolution MR Imaging and Digital Subtraction Angiography for the Characterization and Diagnosis of Intracranial Artery Disease

BACKGROUND AND PURPOSE

High-resolution MR imaging has recently been introduced as a promising diagnostic modality in intracranial artery disease. Our aim was to compare high-resolution MR imaging with digital subtraction angiography for the characterization and diagnosis of various intracranial artery diseases.

MATERIALS AND METHODS

Thirty-seven patients who had undergone both high-resolution MR imaging and DSA for intracranial artery disease were enrolled in our study (August 2011 to April 2014). The time interval between the high-resolution MR imaging and DSA was within 1 month. The degree of stenosis and the minimal luminal diameter were independently measured by 2 observers in both DSA and high-resolution MR imaging, and the results were compared. Two observers independently diagnosed intracranial artery diseases on DSA and high-resolution MR imaging. The time interval between the diagnoses on DSA and high-resolution MR imaging was 2 weeks. Interobserver diagnostic agreement for each technique and intermodality diagnostic agreement for each observer were acquired.

RESULTS

High-resolution MR imaging showed moderate-to-excellent agreement (interclass correlation coefficient = 0.892-0.949; κ = 0.548-0.614) and significant correlations (R = 0.766-892) with DSA on the degree of stenosis and minimal luminal diameter. The interobserver diagnostic agreement was good for DSA (κ = 0.643) and excellent for high-resolution MR imaging (κ = 0.818). The intermodality diagnostic agreement was good (κ = 0.704) for observer 1 and moderate (κ = 0.579) for observer 2, respectively.

CONCLUSIONS

High-resolution MR imaging may be an imaging method comparable with DSA for the characterization and diagnosis of various intracranial artery diseases.

Nonatheroscleotic Isolated Middle Cerebral Artery Disease May Be Early Manifestation of Moyamoya Disease

Background and Purpose—

Middle cerebral artery steno-occlusive disease (MCAD) is not an uncommon cause of ischemic stroke in young Asians. Aside from atherosclerosis, the pathogenesis of MCAD include various nonatherosclerotic vasculopathies, most of which are yet to be defined. This study investigated the pathogenesis of symptomatic isolated MCAD in young Asian patients using high-resolution magnetic resonance imaging (HR-MRI) and mutation analysis of RNF213 .

Methods—

Patients aged <60 years with stroke or transient ischemic attack caused by MCAD were prospectively enrolled. Patients with a confirmed diagnosis of moyamoya disease, dissection, and vasculitis; with significant steno-occlusion in cerebral arteries other than the MCA; or with high-risk cardioembolic source were excluded. Using high-resolution MRI, patients were classified into an atherosclerosis group and a nonatherosclerosis group.

Results—

Eighty-one patients were enrolled, 45 (56.6%) in the atherosclerosis and 36 (44.4%) in the nonatherosclerosis group. The nonatherosclerosis group was significantly younger ( P =0.013), had a smaller number of vascular risk factors ( P =0.001), showed a lower homocysteine level ( P <0.001), thinner intima-media thickness ( P =0.006), and had more frequent heterozygotes at RNF213 ( P =0.045) than the atherosclerosis group. Diffusion-weighted image lesion pattern showed no significant differences in assumed stroke mechanisms between the 2 groups.

Conclusions—

Nonatherosclerotic pathogenesis are common in young Asians with symptomatic isolated MCAD. Clinical findings, high-resolution MRI features, and results of RNF213 mutation analysis suggest that moyamoya disease is responsible etiologically for a significant portion of nonatherosclerotic lesions. Symptomatic isolated MCAD may be an early manifestation of moyamoya disease in young Asian adults.

Post-ischaemic hyperperfusion in traumatic middle cerebral artery dissection detected by arterial spin labelling of magnetic resonance imaging

We report a patient with a traumatic middle cerebral artery dissection, which showed hyperperfusion in the territory supplied by the left middle cerebral artery. A 45-year-old man experienced speech disturbance and motor weakness in his right hemibody on the day following mild head trauma. His symptoms worsened on the fourth day. Magnetic resonance imaging showed narrowing in the left M1 portion of the middle cerebral artery. Angiography showed narrowing and dilatation in the left middle cerebral artery trunk. The lesion was diagnosed as a dissection of the middle cerebral artery. Arterial spin labelling of magnetic resonance imaging and single photon emission computed tomography showed increased cerebral blood flow in the left temporal region compared with the right. The patient was treated conservatively and the symptoms gradually improved. The hyperperfusion observed on arterial spin labelling and single photon emission computed tomography gradually improved and disappeared on the 25th day. This is the first reported case of traumatic middle cerebral artery dissection, which showed post-ischaemic hyperperfusion in the territory of the affected artery. To detect hyperperfusion in the brain, arterial spin labelling is a useful technique.

Quantitative Analysis Using High-Resolution 3T MRI in Acute Intracranial Artery Dissection

BACKGROUND AND PURPOSE

Quantitative measurements, as well as qualitative characterizations, of the vessel walls of the small intracranial arteries became clinically available and reliable beyond the resolution limit of 1.5 T high-resolution magnetic resonance imaging (HR-MRI) with the development of 3 T HR-MRI. We present the quantitative dissection findings of spontaneous and unruptured acute intracranial artery dissection (SID) using 3 T HR-MRI and investigate the differences between each cerebral artery.

METHODS

Twenty-eight lesions (anterior cerebral artery = 6; middle cerebral artery = 4; vertebral artery = 18) from 26 patients (17 male and 9 female patients; mean age = 47 years; age range = 32-74 years) with presumptive diagnoses of SID were included. The diagnosis was determined based on the clinical features, findings on luminal angiography (such as digital subtraction angiography, computed tomography, or magnetic resonance angiography), and HR-MRI. HR-MRI was performed within one month from onset. The neuroimaging indices (maximal outer diameter and area, remodeling index and modified remodeling index, and wall thickness and wall area index) of aneurysmal dilatation and the signal intensities of the intramural hematomas were rated using HR-MRI. The results were compared between each cerebral artery.

RESULTS

The maximal outer diameter and area, remodeling index and modified remodeling index, and wall thickness index and length were significantly different between anterior and posterior circulation (P < .05). The mean relative signal intensities of the intramural hematoma showed consistent values, regardless of the cerebral arteries, without significant difference.

CONCLUSIONS

Neuroimaging indices of aneurysmal dilatation may be adjunctive indicators in the evaluation of SID.

Vessel Wall Imaging of the Intracranial and Cervical Carotid Arteries

Vessel wall imaging can depict the morphologies of atherosclerotic plaques, arterial walls, and surrounding structures in the intracranial and cervical carotid arteries beyond the simple luminal changes that can be observed with traditional luminal evaluation. Differentiating vulnerable from stable plaques and characterizing atherosclerotic plaques are vital parts of the early diagnosis, prevention, and treatment of stroke and the neurological adverse effects of atherosclerosis. Various techniques for vessel wall imaging have been developed and introduced to differentiate and analyze atherosclerotic plaques in the cervical carotid artery. High-resolution magnetic resonance imaging (HR-MRI) is the most important and popular vessel wall imaging technique for directly evaluating the vascular wall and intracranial artery disease. Intracranial artery atherosclerosis, dissection, moyamoya disease, vasculitis, and reversible cerebral vasoconstriction syndrome can also be diagnosed and differentiated by using HR-MRI. Here, we review the radiologic features of intracranial artery disease and cervical carotid artery atherosclerosis on HR-MRI and various other vessel wall imaging techniques (e.g., ultrasound, computed tomography, magnetic resonance, and positron emission tomography-computed tomography).

High-Resolution Magnetic Resonance Imaging of Intracranial Vertebral Artery Dissecting Aneurysm for Planning of Endovascular Treatment

The equipment and techniques associated with magnetic resonance imaging (MRI) have rapidly evolved. The development of 3.0 Tesla MRI has enabled high-resolution imaging of the intracranial vessel wall. High-resolution MRI (HRMRI) can yield excellent visualization of both the arterial wall and lumen, thus facilitating the detection of the primary and secondary features of intracranial arterial dissection. In the present report, we describe the manner in which HRMRI affected our endovascular treatment planning strategy in 2 cases with unruptured intracranial vertebral artery dissection aneurysm. HRMRI provides further information about the vessel wall and the lumen of the unruptured intracranial vertebral artery dissecting aneurysm, which was treated by an endovascular approach in the 2 current cases.

Association of Intraplaque Hemorrhage and Acute Infarction in Patients With Basilar Artery Plaque

BACKGROUND AND PURPOSE

High-resolution magnetic resonance imaging (HRMRI) is ideal for serial examination of diseased arterial walls because it is noninvasive and has superior capability of discriminating tissue characteristics. The aim of this study is to evaluate the prevalence and clinical relevance of intraplaque hemorrhage (IPH) in patients with basilar artery (BA) atherosclerosis using HRMRI.

METHODS

We analyzed HRMRI and clinical data from 74 patients (45 symptomatic and 29 asymptomatic), all of whom had >50% BA stenosis. High-signal intensity within a BA plaque on magnetization-prepared rapid acquisition with gradient-echo was defined as an area with an intensity that was >150% of the signal from the adjacent muscle. The relationship between IPH within a BA plaque region and clinical presentation was analyzed.

RESULTS

Thirty patients were positive for IPH on HRMRI (42.3%, 24 symptomatic and 6 asymptomatic). Symptomatic lesions in the MR-positive IPH group were significantly more prevalent than in the MR-negative group (80.0% versus 48.8%; P<0.01). Also, MR-predicted IPH was significantly more prevalent in the high-grade stenosis group (P<0.001) than in the low-grade group. The relative risk of an acute focal stroke event among patients who were magnetization-prepared rapid acquisition with gradient-echo-positive for IPH compared with patients who were magnetization-prepared rapid acquisition with gradient-echo-negative was 1.64.

CONCLUSIONS

IPH within a BA plaque region on HRMRI is highly prevalent and is associated with acute stroke.

Isolated middle cerebral artery dissection: a systematic review

Acute stroke can be missed in the emergency department, particularly in younger patients and in those with more vague symptoms such as headache or dizziness. Cervicocephalic dissections are one group of etiologies for acute stroke in the young. While cervicocephalic dissections are not uncommon in clinical practice, isolated middle cerebral artery dissection (MCAD) has been rarely reported as a cause for stroke. We sought to review the clinical implications and pathophysiology of an isolated MCAD. We searched the medical literature for isolated MCAD in clinical stroke patients using MEDLINE, HighWire, and Google Scholar databases from 1966 to 2013 using the keywords 'middle cerebral artery dissection,' 'intracerebral artery dissection,' and 'middle cerebral artery dissection stroke.' We reviewed cases to learn various characteristics of isolated MCAD. A total of 61 cases (62.3% male, mean age 44.16 ± 19.17 years) were reviewed from 54 publications. Most cases were reported from Asian countries (78.7%). Ischemic strokes were more common than hemorrhagic strokes (68.9%). Digital subtraction angiography was the most common imaging modality used to diagnose isolated MCAD (75.4%). Surgery was the preferred form of therapeutic intervention (39.3%). Males (n = 27/48, p = 0.0008) and those who presented with only ischemic syndromes (n = 22/48, p = 0.0009) had significantly higher rates of favorable outcome. Isolated MCAD is a rare disease that can contribute to the stroke burden of young patients. Further studies are needed to better characterize optimal treatment strategies and define outcomes for this rare condition.